Exam 2 - Ch. 18 Planning Nursing Care

Discuss the difference between independent, dependent and collaborative nursing interventions.

*Independent: - Initiated by nursing - Do not require an order from another professional - Based on scientific rationale *Dependent: - Actions that require an order from a physician or other health care provider - Advanced practice nurses may write dependent nursing interventions *Collaborative Interventions: Interdependent - Therapies that require the combined knowledge, skill, and expertise of multiple health care professionals. Ex. Interdisciplinary team meetings.

Explain the SMART approach to writing goal and outcome statements.

*Specific/Singular - Each goal/outcome should address only 1 behavior or response *Measurable - Descriptive terms: quality, quantity, frequency, length, or weight. Avoid "normal", "stable", "acceptable". *Attainable - Mutually set with the patient. Nurse and patient agree on the direction of care. *Realistic - Provide patients a sense of hope, motivation, and accomplishment. *Timed - Time frame for each goal and expected outcome.

Discuss the difference between a goal and an expected outcome.

*goal - broad statement that describes a desired change in a patient's condition, perceptions, or behavior. *expected outcome - measurable change (patient behavior, physical state, or perception) that must be achieved to reach a goal

Discuss criteria used in priority setting.

- Urgency of the problem - The patient's safety and desires - The nature of the treatment indicated - The relationship among the diagnoses

14. A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort? 1. Engage the patient in setting mutual outcomes for distance he is able to walk 2. Confirm with the patient's health care provider about ambulation goals 3. Have physical therapy assist with ambulation 4. Refer to medical record regarding nature of patient's physical problem

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15. A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first? 1. Reconnect the drainage tubing 2. Inspect the condition of the IV dressing 3. Obtain the next IV fluid bag from the medication room 4. Explain when the health care provider is likely to visit

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11. A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities? (Select all that apply.) 1. Policy for conducting hourly rounds 2. Staffing level 3. Interruption by staff nurse colleague 4. RN's years of experience 5. Competency of patient care technician

1, 2, 3

10. Which of the following factors does a nurse consider for a patient with the nursing diagnosis of Disturbed Sleep Pattern related to noisy home environment in choosing an intervention for enhancing the patient's sleep? (Select all that apply.) 1. The intervention should be directed at reducing noise. 2. The intervention should be one shown to be effective in promoting sleep on the basis of research. 3. The intervention should be one commonly used by the patient's sleep partner. 4. The intervention should be one acceptable to the patient. 5. The intervention should be one you used with other patients in the past.

1, 2, 4

2. A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.) 1. Assess condition of skin before making the call 2. Rely on the nurse specialist to know the type of surgery the patient likely had 3. Explain the patient's response emotionally to the repeated leaking of stool 4. Describe the type of bag being used and how long it lasts before leaking 5. Order extra colostomy bags currently being used

1, 3, 4,

3. It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? (Select all that apply.) 1. Using a standardized checklist for essential information 2. Asking the wife to briefly leave the room 3. Completing the hand-off without inviting questions 4. Doing prework such as checking laboratory results before giving a report 5. Including the wife in the hand-off discussion

1, 4, 5

9. An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. Goals Outcomes 1. _____ Patient will ambulate independently in 3 days. a. Patient expresses fewer nonverbal signs of discomfort within 24 hrs. 2. _____ Patient will be injury free for 1 month. b. Patient increases calorie intake to 2500 daily. 3. _____ Patient will achieve 5-lb weight gain in 1 month. c. Patient walks 20 feet using a walker in 24 hrs. 4. _____ Patient will achieve pain relief by discharge. d. Patient identifies barriers to remove in the home within 1 week.

1-c, 2-d, 3-b, 4-a

Discuss the process of selecting nursing interventions during planning.

1.) characteristics of the nursing diagnosis 2.) goals and expected outcomes 3.) evidence base for the interventions 4.) Feasibility of the intervention 5.) acceptability to the patient 6.) your own competency.

6. A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient? 1. Achieving wound healing of the foot ulcer 2. Enhancing patient knowledge about the effects of diabetes 3. Providing a dietitian consultation for diet retraining 4. Improving patient adherence to diabetic diet

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5. Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? (Select all that apply.) 1. Numbered order of diagnosis on the basis of severity 2. Notion of urgency for nursing action 3. Symptom pattern recognition suggesting a problem 4. Mutually agreed on priorities set with patient 5. Time when a specific diagnosis was identified

2, 3, 4

8. A patient has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? (Select all that apply.) 1. Providing mouth care every 4 hours 2. Maintaining intravenous (IV) infusion at 100 mL/hr 3. Administering prochlorperazine (Compazine) via rectal suppository 4. Consulting with dietitian on initial foods to offer patient

2, 4

1. A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first? 1. Giving the enema on time 2. Talking with the patient about her past experiences with illness 3. Talking with the patient about her concerns and acknowledging her sense of unfairness 4. Beginning instruction on postoperative procedures

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12. A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.) 1. IV site not tender 2. Uses cane to walk 3. Walked to end of hall 4. No shortness of breath 5. Slept better during night

3, 4

13. A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 1/2NS. Which intervention is a dependent intervention? 1. Reporting hand-off at change of shift 2. Ambulating patient down hallway 3. Sleep hygiene 4. IV fluid administration

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4. A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? 1. Patient will be turned every 2 hours within 24 hours. 2. Patient will have normal bowel function within 72 hours. 3. Patient's skin integrity will remain intact through discharge. 4. Erythema of skin will be mild to none within 48 hours.

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7. The nurse writes an expected outcome statement in measurable terms. An example is: 1. Patient will have normal stool evacuation. 2. Patient will have fewer bowel movements. 3. Patient will take stool softener every 4 hours. 4. Patient will report stool soft and formed with each defecation.

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Explain the relationship of planning to assessment and nursing diagnosis.

Assessment of a patient will lead to a diagnosis. Based on the diagnosis the nurse can then make a plan to fix the patient's problem.

Describe the role communication plays in planning patient-centered care.

Communication between the patient, patient's family, and other healthcare professionals will better set a realistic goal to fix the patients problem.

Explain the benefits of using the nursing outcomes classification.

For each NANDA-I nursing diagnosis there are multiple NOC suggested outcomes. - The outcomes have labels for describing the focus of nursing care and include indicators (expected outcomes) to use in evaluating the success with nursing interventions. - The indicators for each NOC outcome allow measurement of the outcomes at any point on a five-point Likert scale from most negative to most positive. Such a rating system adds objectivity to judging a patient's progress. - Many health care institutions use NOC as part of the infrastructure of their documentation system. Using standardized nursing terminologies such as NOC makes it more possible to measure aspects of nursing care on a national and international level. For example, when researchers compare databases that have used the standard terminologies from NOC, they can determine which common nursing interventions favorably impact outcomes.

Describe the consultation process.

Six Steps to Consultation: 1. Identify the general problem area 2. Direct consultation to the right professional 3. Provide consultant with relevant info about problem 4. Do not prejudice or influence consultants. 5. Be available to discuss consultant's findings and recommendations 6. Incorporate consultant's recommendations into care plan